Evaluation & Management (E/M) - Articles

We recently fielded the question, “What is medical necessity and how do I know if it's been met?"
The AMA defines medical necessity as:
It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...

In 2018, Medicare announced their plans for revamping the Evaluation and Management coding structure and was met with a rapid response from the medical community, including the AMA and many other organizations. As a result, the Medicare changes implemented in 2019 were mostly documentation-related changes that generally benefited providers but were not ...

Our E/M Calculator takes the stress out of leveling Evaluation and Management codes. This tool can be used by auditors, as well as coders and students learning E/M coding. Calculate based on Time or Components. The exam portion lets you chose either 95, 97 Guidelines or both.
Included with our Professional and Facility Subscription!
...

Prior years:(click bar to view articles)

2018

It seems like a simple code to bill, but CPT 99211 (established patient office visit) is by no means a freebie when it comes to documentation and compliance. This lowest level office visit code is sometimes called a "nurse visit" because CPT does not require that a physician be present...

The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and ...

Time, as it applies to E/M codes, has often been viewed as an "if/then" proposition. "If" the documentation shows that a majority of the encounter was based on counseling and/or coordination of care, "then" we choose the highest level of service based on the total time of the encounter.
However, a ...

The biggest thing modifiers 25 and 57 have in common is that they both assert that the E/M service should be payable based on documentation within the record showing the procedure should not be bundled into the E/M. After that, the similarities end, and it is important to know the...

The proposed E&M changes by CMS would decrease provider administrative work burden by, per CMS, 51 hours a year; however, how will reducing documentation requirements truly affect the professionals of the healthcare industry? First, let’s discuss the 30,000-foot overview of the most impactful E&M changes—which is the change to the...

On July 16th 2018, anyone subscribed to the CMS Quality Payment Program received an e-mail containing a letter to doctors from Seem Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS). There are some widespread changes proposed in this letter of which you need to be aware.
Where ...

As coders and auditors, we are taught the documentation guidelines on how to determine medical decision making. However, Medicare is clear that medical necessity is what determines the overall payment. In order to know what to do when medical necessity and medical decision making do not line up, you must...

In an effort to show CMS is committed to changing the rules to accommodate their providers CMS released a letter to Doctors of Medicare Beneficiaries. The letter offers encouragement and a promise to reduce the burden of unnecessary rules and requirements. The letter states “President Trump has made it clear that ...

According to CMS changes are coming for E/M codes. A recent proposal from CMS stated: "The E/M visit code set is outdated and needs to be revised and revalued." Since podiatry tends to furnish a lower level of E/M visits, CMS is proposing new G-codes to report E/M office/outpatient visits. The proposed ...

New evaluation codes for physical therapy (PT) and occupational therapy (OT) codes were made effective 1/1/2017. Three new physical therapy evaluation codes replaced 97001, and three new occupational evaluation codes replaced 97003. Chart 1 - Short Code Descriptors The PT and OT reevaluation codes remain the same but were...

According to WPS, when billing or coding for E/M services you should follow a few guidelines.
Documentation must support the level of service billed and the medical necessity for the level billed. Below are additional tips for services which commonly incur CERT error findings for insufficient documentation.
Critical Care Visits
Clear indication of patient ...

In order to understand and answer the question, "Why code 99080 is being denied when billed with an E/M Service, it is important to first review the requriements of selecting the appropriate level of Evaluation and Management service and how that relates to reporting a 99080 special report service. Continue reading for better understanding.

Question: I have a provider that provides Department of Transportation (DOT) exams. I have found ICD-10 code Z02.4 (encounter for examination for drivers license) but I am unsure which CPT Code to use. Would I still use 99203 or 99204?

Question
Are there consultation codes that can be used for new and existing patients when a review of systems and detailed history is performed but no examination due to the patient's reluctance to make a decision to continue with the visit but has taken up 30-45 minutes of the doctors time?

What is the definition of Office Visit? Can It be billed with a Chiropractic Treatment? What about using code 99123 E&M code for office visits? Can we bill of office visits even though we are giving chiropractic care?

Reporting the performance of range of motion testing (95851-95852) at the same encounter of an Evaluation and Management (EM) service, produces an NCCI edit resulting in payment for the EM service and denial of the ROM testing. Read the article to learn what other codes ROM testing is considered incidental to.

2017

With CMS looking to gradually revise its E/M documentation requirements to reduce the burden and complexity they pose to providers, it's a great time to review the trickiest E/M component: medical decision making (MDM)....

According to the recently released 2018 Physician Fee Schedule Proposed Rule, published in the Federal Register, dated July 21, 2017, the Centers for Medicare & Medicaid Services (CMS) acknowledges that the current Evaluation and Management (E/M) documentation guidelines create an administrative burden and increased audit risk for providers. In response, ...

Have you ever had a patient take more time with the provider than they were scheduled for? Do you understand which codes to report and the rules that govern them to allow for better reimbursement?
Prolonged Service codes were created just for that reason but you must carefully follow the documentation ...

At times, there are patients who require prolonged face-to-face time with the provider to discuss or be counseled about their condition, plan of care, risks, complications, alternative therapies, or other medical issues. When E/M services go wild, taking significantly longer than the typical time associated with it, that direct face-to-face ...

According to 2017 Current Procedural Terminology (CPT), a Consultation is a type of E&M service provided by a physician at the request of another physician or other appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of ...

Evaluation and Management (E/M) codes are defined by the AMA Current Procedural Terminology (CPT®) codebook and while they are the most commonly utilized CPT codes, their code descriptions have not changed in years.

The final sub-component of Medical Decision Making is the Risk of Significant Complications, Morbidity and/or Mortality. The following is the official Evaluation and Management Table of Risk. The level is selected by choosing one element from three criteria (Presenting Problem, Diagnostic Procedures Ordered, and Management Options), with the highest level selected ...

There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them. Double dipping occurs when the same information is used in more than one of the subcomponents of history.
The subcomponents of history include:
Chief Complaint ...

As a chiropractor, we use E/M codes frequently, but not at every encounter, as do our medical counterparts. These are the CPT codes used to describe the work involved in figuring out what is wrong with a patient and creating a plan to manage them. One of my good friends, ...

2016

E/M stands for "evaluation and management". E/M coding is the process by which provider-patient encounters are translated into five digit CPT codes to facilitate billing. CPT stands for "current procedural terminology." These are the numeric codes which are submitted to insurers for payment. Most billable procedures have their own CPT ...

Anesthesia services are billed using CPT® codes 00100-01999. These CPT® codes are cross-walked to surgical codes. The crosswalk is available from the American Society of Anesthesiologists at www.asahq.org. Each anesthesia code has a base unit assigned to it. The anesthetist also bills the number of time units, with a single...

According to the CPT® book, E/M services are divided into categories and subcategories. Office services are divided into new and established patient visits. Consultations are divided into outpatient/office consults and inpatient consultations. The E/M services typically have three to five levels of services and these levels are not interchangeable from...

2015

Hospital services are all defined by CPT® as per day codes, that is, all of the care provided to a hospitalized patient during the calendar day. If a physician (or that physician's covering partner of the same specialty) sees the patient a second time during the calendar day, a second visit is...

The Documentation Guidelines describe family history as:
a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk
This family history is a review of the illness's, health status, and cause of death of close members of the patient's...

Modifiers in Postoperative Periods
Introduction
Documenting the events of a patient visit is not always the simplest and most straightforward of processes. Many variables affect which information must be included in order to report a procedure or service accurately. Global periods are one of...

Are the following statements true or false?
• The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules.
• The surgeon can never be paid to do a pre-op visit if s/he is going to take the patient to surgery.
• The...

Have you ever read a physician office note and thought it was strangely familiar? Or, not just familiar but identical to another note? Well, Medicare contractors have noticed the same thing, and the Office of Inspector General has included this on their 2011 Work Plan.
Medicare contractors have...

Subsequent nursing facility visits are reported with codes 99307--99310. These codes are defined as per day codes, and do not have new and established patient divisions. There are also initial nursing facility codes, which only a physician may use. A physician or NPP may use the subsequent...

Chart audits frequently examine coding associated with lesion removals and wound repairs. In order to assign the appropriate procedure code, certain documentation must be included in the medical record, such as lesion type, excision size, wound repair, and location. Without these important details,...

There are sample audited notes in resource section.
99213 is an established patient visit which requires 2 of 3 of the following components:
An expanded, problem focused history, which is 1-3 HPI elements and 1 system in ROS reviewed
An expanded, problem focused exam, which is 6 bullets from...

According to the CPT® book, E/M services are divided into categories and subcategories. Office services are divided into new and established patient visits. Consultations are divided into outpatient/office consults and inpatient consultations. The E/M services typically have three to five...

At a coding session at a recent Pri-Med conference a Pediatrician asked this question:
"I had wheezer in the office, and he was in the office a long time. I examined him, we did pulxe oximetry measurements, which we never get paid for both before and after a nebulizer treatment. I was in and...

The Documentation Guidelines say social history is:
an age appropriate review of past and current activities.
As auditors, we interpret this to include:
smoking, alcohol and drug use
living arrangements
employment history
school history
support system, if relevant
In...

Modifier 25: Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. Refer to the CPT® book for the complete definition. Modifier 25 is appended to the E/M service, never to a procedure.
The decision about whether to bill for...

Can’t we bill a low level E/M with every procedure?
No!
Medicare says this:
Per CCI (chapter 11, Letter R.): “The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. ...

I can count on two consistent issues in coding audits. Doctors report that their patients are, in general, sicker than patients in other practices. Coders report that their physicians are, in general, worse documenters than physicians in other practices and select codes that are too high based on...

Physicians are often confused about whether to bill for observation status or inpatient status for patients admitted to the hospital. There are specific rules in the Medicare Claims Processing Manual, but sometimes the question is: what is the status of the patient?
Commercial carriers have long...

How to Research Answers to Coding Questions
Perform a search of the discussion board or listserv website prior to posting a new question. For your search terms, include specific words such as the diagnostic statement or procedure statement or the specific code number or ...

Can I use modifier 25 on an E/M service on the same day as a preventive medicine exam
Let’s review what a preventive medicine service is, in order to answer that question. Preventive medicine services are:
• The description given by CPT® for “annual physicals”
•...

Does anyone remember the good old days, when you didn't need to know the patient's insurance to select a category of code? Now, correct selection of an E/M category of code requires the clinician and coder to consider:
Where the service was performed
The status of the patient...

According to the American Medical Association’s CPT® book, a new patient is a patient who “has never received professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years.
There is an excellent...

Modifier 25 for Preventive medicine service and office visits
The CPT® book describes modifier 25 as the modifier to be used on an E/M service when "a Significant, Separately Identifiable Evaluation and Management Service” is performed by the same physician on the same day of the...

2014

Four new CPT® codes that got some attention when the 2014 CPT® changes were released late last year were a new E/M code series, 99446-99449, designed to be reported when a consulting provider offered a telephone or Internet E/M service that included a verbal and written report back to the...

The Comprehensive Error Rate Testing (CERT) program Medicare uses to assess the accuracy of provider billing has uncovered a big source for mistakes – documentation problems when a patient is receiving psychotherapy services on the same date as an E/M encounter, according to CMS.
There are...

One of the areas where the OIG has its sights set in 2014 is on physician documentation. The OIG plans to review documentation of E/M services looking for what it describes as “documentation vulnerabilities.”
Put more specifically, the OIG reports that Medicare Administrative...

2013

Medicare will typically pay for a hospital discharge service (billed with 99238-99239) and a nursing facility admission visit (99304-99306) when billed on the same date of service (DOS) by the same provider without the need for a modifier. As always, however, there are a couple of exceptions.
The...

There is no CPT® code for the Mini Mental Status Exam.
Physicians use the mini mental status exam (MMSE to test a patient's cognitive function. The test is made up of a set of questions, testing the patient’s memory, orientation and arithmetic calculation skills.
There is a...

Introduction
The past year has been an exciting time for healthcare professionals, bringing more changes, opportunities and challenges than ever before. The Health Information Technology for Economic and Clinical Health (HITECH) Act, which is a portion of the American Recovery and Reinvestment Act...

2011

Now that Medicare doesn't recognize consults (effective 1-1-10), how will we bill for patients who have a commercial insurance as primary, and Medicare as a secondary payer? There are no great options.
Options for office “consults”
Bill primary with consult codes. Will cross...

2010

,Physician visits in a nursing home are billed with nursing facility codes and place of service. But, what if a physician opens an office there? Are those services billed as office visits?
A physician practice may established an office in a nursing home, if it pays rent at market value, and is...

Either a physician or an NPP may bill for discharge services from a skilled nursing facility or a nursing facility. There are two discharge day management codes from a nursing facility. 99315 is for discharge day management 30 minutes or less, and 99316 is for discharge day management over 30...

CPT® code 99318 is used to bill an annual nursing facility assessment. It requires three of three of these components: a detailed interval history, a comprehensive exam, and low or moderate medical decision making.
This visit is payable once per year for a resident in a nursing facility. ...

Subsequent nursing facility visits (99307--99310) are services billed for either mandated or medically necessary visits in a skilled nursing facility or nursing facility. (Place of service 31 for a skilled nursing facility or 32 for a nursing facility). These codes may also be used in place of...

An "Eye" on Coding
Ophthalmology coding is an interesting specialty, especially when it comes to assigning a level of evaluation and management code. Coders outside this specialty may not realize that there are two sets of codes available to the eye specialist. The first set is one...

A common question amongst coders that routinely deal with E&M services.
The E&M Guidelines specify which elements can be recorded by someone other than the physician. "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the...

Updated: Dec 16, 2009
By now, we have all heard that CMS will not pay for consuts starting Jan 1, 2010, but we had lingering questions about how to submit claims. Dec 15, CMS released a transmittal, dated Dec 14, 2009, which answers these questions. The transmittal is attached.
For services that...

No, a practice may not bill a nurse visit to Medicare in a Rural Health Clinic (RHC.)
Rural Health Clinics are designated by Medicare. In some states, the RHC will also be designated as a RHC by Medicaid. When so designated, the clinic is paid an all-inclusive rate for services performed on that...

Medically necessary pre-operative evaluations are covered services by Medicare and other third party payers. Typically, the surgeon who will perform the surgery asks the patient's primary care physician or sub-specialist to clear the patient prior to a major surgery. This service must be medically...

2009

Change: December 15, 2009--Good news!
The consult change would seem to allow hospitalists to bill for post op care using the initial hospital care codes. Here is a post by Seth Canterbury, published with his kind permission, about the topic.
I read it to allow everyone's initial inpatient visit...

By now you've heard the news that starting January 1, 2010, Medicare will no longer reimburse consultation services billed with codes 99241--99245, 99251--99255. But, the consult codes remain in the CPT® book for 2010. However, there is quite a bit of new editorial material related to...

For most primary care physicians, Evaluation and Management services comprise the highest percentage of services performed, and account for most of the revenue. Primary care physicians should regularly compare their profile with the norm for their specialty. These specialty norms are included as a...

Observation services are a status of admission to the hospital. Patients who are admitted to the hospital are admitted either to inpatient status or observation status. The status is determined by the physician, although often the case manager at the hospital will have significant input into the...

This is an article describing using prolonged services codes in an office setting. There is a separate article in Codapedia about using prolonged services codes in an inpatient setting. There is an article describing using non-face-to-face codes, as well.
Prolonged services codes are add-on...

Medicare does not pay for routine physical exams annually for patients--a sore spot for Primary Care Providers and Medicare beneficiaries alike. They do pay for an initial Welcome to Medicare visit. (See the Codapedia article about that topic.)
Medicare does pay for a screening pelvic and breast...

Is it appropriate to bill an E/M service with a chemotherapy infusion?
Here is how Nancy Maguire answered that question:
If a significant separately identifiable evaluation and management service is performed, the appropriate E & M code should be reported utilizing modifier 25 in addition to...

Question: Can you bill a nurse visit, 99211, to Medicare in a Provider Based Entity?
Answer: You may not bill a nurse visit to Part B, for a physician service, but may bill a facility fee for a nurse visit in a PBE.
Discussion:
Discussion:
The payment rules for a free-standing,...

According to the CPT® book, assisted living services are reported with codes 99324--99337. Look at that series of codes for new or established patients. It is not correct to bill at an assisted living facility with office visit codes. These codes are used for services provided in: domiciliary,...

Does an E/M service require an exam? It depends on the category of service.
Established patients and subsequent hospital visits require two out of three of the key components, history, exam and medical decision making. Any two components at the level of documentation required determines the level...

By Jeannie Cagle, BSN, RN, CPC
This question appeared in a recent list serve. My two responses are based upon two different assumptions: (1) both providers are physicians, and (2) one of the providers is not a physician. The principal points are that each physician has a unique National Provider...

New patient codes 99201–99205 may be billed in an office, outpatient department or Emergency Department.
What is a new patient?
The CPT® and Medicare (CMS) definition are the same. From the CPT® book:
A new patient is one who has not received any professional services from the...

How does a physician report performing a Department of Transportation physical? With CPT® code 99455 and ICD-9 code V70.5, 99455 is for a work related or medical disability examination by the treating physician. (9945 is for this examination by other than the treating physician.) See the...

If a physician removes sutures that he/she placed, and the service has a ten day global period, there is no separate payment for the suture removal. It is part of the global service and payment for the minor procedure.
However, insurance companies will pay for suture removal performed by a...

When documenting the history components in an Evaluation and Management service, the clinician is not required to use the headings that the Documentation Guidelines define. That is, the history section does not need to be labeled: History of the Present Illness, Review of Systems, and past medical,...

Is time a trump card in selecting an Evaluation and Management service?
Sometimes. Isn't that too frequently the answer in coding?
If the visit meets the criteria for using time ot select the code, and if time is a descriptor in the CPT® definition, then yes.
The criteria are:
...

Physicians who treat patients with very serious illnesses sometimes think that they can select the highest level of service in any category based on the high acuity of the patient. After all, isn't a patient with a brain cancer really sick? Shouldn't that patient always be charged a high level...

There are no longer any CPT® codes for confirmatory consults. If a patient presents to the office with a request for a second opinion, how is that billed?
If the patient is requesting a second opinion, bill that service as a new or established patient, whichever category is correct for that...

There are two codes for ventilator management for inpatient services: 94002 and 94003. One is for the day when the physician initiates vent management and the second is for a subsequent day. They are mutually exclusive codes in the CCI edits and may not be billed together on the same day. See the...

A patient presents to the office with 100 pages of old records and a dozen x-ray copies to review prior to consultation. How can a physician be paid for that?
There is no separate reimbursement for record review. With the development of RBRVS, the pre and post work of services is included in the...

Yes, both inpatient and outpatient consults may be coded based on time, when the conditions for using time are met.
CPT® tells us that a physician or NPP may use time to select a code when counseing "dominates" the visit. CMS confirms these rules in their Documentation Guidelines....

Physicians should bill for patients in facilities based on the status of the patient in the facility. This is true for Observation, Inpatient and nursing facility status. The status billed by the facility and the E/M codes selected and reported by the physician should match.
Some hospitals have...

Sometimes, when auditing an initial hospital service, either the history or the exam does not meet the level required for the lowest level of initial hospital service. 99221 requires all three of: a detailed history, a detailed exam and straightforward or low medical decision making. The MDM is...

There are two sets of prolonged services codes, one set for face-to-face additional time spent with the patient in the office or hospital, and one set for non-face-to-face time. Non-face-to-face time is typically not paid by most insurers. In 2009, CPT® changes its description of these...

This question comes up at seminar after seminar. Someone says, "My billing manager told me that PAs (or NPs) can't do consults. Is that true?" It is a half truth.
PAs and NPs may perform consults, as long as consults are in their state scope of practice. They may perform consults on...

This is one of the most common questions physicians and NPPs ask at coding conferences. Do I need to document three vital signs for it to count.
It depends on which set of guidelines the clinician is using.
For 1995, no. Any one vital sign or general appearance counts for constitutional.
For...

A comprehensive exam using the 1995 Guidelines requires eight organ systems. You may not count body areas. The Guidelines do not give any definition about how much must be examined in each system, and auditors typically count anything within that system. The Guidelines say,
Comprehensive -- a...

In 2007, CPT® added two codes for anticoagulant management, 99363 and 99364. The codes are meant to be used by physicians and Non-Physician Practitioners (NPPs) who manage a patient's warfarin therapy on an outpatient basis, reviewing the PTINR, adjusting the patient's dosage as appropriate,...

Can one physician request a consult from another physician in the same group?
Sometimes. (Don't we long for yes or no answers?)
One physician can request a consult from another physician in the same group, of the same or different specialty, when the conditions of a consult are met, and the...

Hospitals are adding hospitalist services at a fast pace. Everyone is recruiting for hospitalists. It's changed the face of primary care. Primary care physicians are now in their offices more hours of the day. Their hospitalized patients are cared for by a group of physicians without office...

There is only one code for observation day discharge management, 99217. Unlike discharge day management from inpatient status or nursing homes, there are not two levels based on time. Use 99217 no matter how long the discharge takes.
The patient status must be Observation status to use this...

Use codes 99238 or 99239 for services provided to a patient being discharged from inpatient status in the hospital. These codes include all of the work performed on the calendar day to discharge a patient, including the exam, discussion with the patient and caregivers, and discharge paperwork. ...

Auditors breathed a huge sigh of relief when the 1997 Guidelines were released. The exam component was specific, clear and defensible in all four areas: problem focused, expanded problem focused, detailed and comprehensive. There were even specific instructions for single specialy exam elements. ...

What are mandated nursing home visits and who mandates them? May either a physician or qualified Non-Physician Practitioner (NPP) perform these?
CMS mandates that residents in nursing homes be assessed by a physician or NPP at periodic intervals. This is a requirement for the nursing home's...

Medicare and other third party payers pay have specific rules for paying physicians of the same specialty in a group. Here is what the Medicare Claims Processing Manual says:
30.6.5 - Physicians in Group Practice
(Rev. 1, 10-01-03)
Physicians in the same group practice who are in the same...

There are times when physicians or NPPs see a patient twice in a single day, and want to know if both are reportable, and if both are paid by insurances or Medicare. In general, only one service is paid, but there are some instances in which both can be paid.

CMS and other payers collect data on the utilization of E/M services within each category of service. For example, for all of the established patient visits billed using codes 99211 to 99215 by Rheumatologists, CMS keeps track of what percentage are level one’s, level two’s, level...

Let’s start with Medicare’s definition of a consultation
Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.10A
Carriers pay for a reasonable and medically necessary consultation service when all of the following criteria for the use of a consultation code...

Only the time of the teaching physician--not the resident--may be reported as critical care time. That's the short answer.
Review the articles in Codapedia related to the requirements for critical care billing and critical care to neonates and pediatric patients.
Only the attending physician...

Critical care services are services provided to a critically ill patient. It sounds like a circular definition.doesn't it? The first requirement for billing critical care is the status or condition of the patient. Although critical care services are often provided in a criticla care unit,...

Welcome to Medicare
Initial Preventive Physical Examination (IPPE)
A new benefit under the Medicare Modernization Act
Effective date 1-1-05, changes for 2009
Eligibility: Any Medicare beneficiary who enrolls in Medicare on or after January 1, 2005
Time limits: Eligible for benefit in the...

CPT® defines two sets of consultation codes: outpatient/office consults using 99241 through 99245 and inpatient/nursing facility consults using codes 99251 through 99255.
The Center for Medicaid and Medicare Services (CMS) defines a consult in this way
Specifically, a consultation service is...